considering human factors in process hazard · pdf fileconsidering human factors in process...

Considering Human Factors in Process Hazard Analysis

Cantemir Mambet 1

Petroleum Club Romania, September 2015

Objective:

Describe how to consider Human Factors and human failures

in Process Hazard Analysis (PHA)

Contents:

- Human factors and human failures in PHA

- Relationship between human factors and human failures

- Approaches to treatment of human failures

- Approaches to treatment of human factors

- Examples, back-up slides

Human Factors

discipline dealing with the psychological, social, physical,

biological and safety characteristics of a user and the system the

user is in.

It is sometimes used synonymously with ergonomics, but ergonomics is

actually a subset of Human Factors.

Cantemir Mambet3

Definitions

Risk Management

Coordinated activities to direct and control an organization with

regard to risk.

(ISO 31000:2009, [2.20])

Risk

'effect of uncertainty on objectives'

(ISO 31000:2009, [2.13])

Human Factors Analysis and Classification System (HFACS)

general human error framework originally developed and tested

within the U.S. military as a tool for investigating and analyzing the

human causes of aviation accidents (Wiegmann & Shapell, 2001)

Cantemir Mambet 4

Definitions:

Hazard

'hazard' shall mean the intrinsic property of a dangerous substance

or physical situation, with a potential for creating damage to human

health and/or the environment

(Seveso III Directive, 2012/18/EU Art. 3 – para. 14)

Process Hazard Analysis (PHA):

Process Hazard Analysis (PHA) (or Process Hazard Evaluation) is a

set of organized and systematic assessments of the potential

hazards associated with an industrial process.

A PHA is directed toward analyzing potential causes and

consequences of fires, explosions, releases of toxic or flammable

chemicals and major spills of hazardous chemicals, and it focuses on

equipment, instrumentation, utilities, human actions, and external

factors that might impact the process.

(https://en.wikipedia.org/wiki/Process_Hazard_Analysis)

Cantemir Mambet 5

Definitions:

- PHA is a thorough, orderly, and systematic approach for

identifying, evaluating, and controlling the hazards of processes

involving highly hazardous chemicals.

- A PHA provides information intended to assist managers and

employees in making decisions for improving safety and reducing the

consequences of unwanted or unplanned releases of hazardous

chemicals.

- The facility shall perform a process hazard analysis on all

processes covered by the applicable standards.

Cantemir Mambet 6

Definitions:

Process Hazard Analysis (PHA)

Cantemir Mambet 7

WHY?

EU Major Accident Prevention Policy and Safety Management System

- Required by Council Directive 96/82/EC (Seveso II)

since June, 2015, Seveso III 2012/18/EU [BACK-UP SLIDES]

- Preparation of a Safety Report to meet the requirements of

Council Directive 2012/18/EU Seveso III (Art. 10)

- Among the seven fundamental elements that should be included in

the Safety Management System:

PHAs that identify and evaluate the major hazards

- Failures of the management system were shown to have

contributed to the cause of over 85% of the accidents reported.

Cantemir Mambet 8

HOW?

Human factors are included in a PHA in two ways:

- Human failure is analyzed as a cause of hazard

scenarios and

- Factors that impact human performance are studied

and analyzed

*Together with the Safety Report, PHA and Risk Analysis

must be reviewed and updated every five years or whenever

necessary. [BACK-UP SLIDES]

Cantemir Mambet 9

HOW?

*Human factors engineering deals with:

- Person-process and person-person interfaces

- How they influence the performance of people

*Human failure analysis deals with:

- Failures people may make in their interface with an

engineered process

These failures and their rates are influenced directly

by the human factors engineering design of the

process [BACK-UP SLIDES]

Cantemir Mambet

HOW?

HUMAN FACTORS MODEL

Process

Organization

People

Environment

10

HOW?

SYSTEMS VIEW OF HUMAN ERROR

Vulnerability(unforgivingconditions)

Error-inducingenvironment

Humanlimitations

Errors withlikelihood ofsignificantconsequences

11Cantemir Mambet

Cantemir Mambet 12

HOW?

How to consider Human Factors and

human failures in

Process Hazard Analysis (PHA)?

Cantemir Mambet 13

HOW?

“Structural Engineering is the art of molding materials we do not

really understand into shapes we cannot really analyze, so as to

withstand forces we cannot really assess, in such a way that the

public does not really suspect.”

(Dr. E. H. Brown - Structural Analysis Volume One, 1967)

SYSTEMS VIEW OF HUMAN ERROR ?????

Examples from other disciplines:

Cantemir Mambet 14

DIFFERENCE

HUMAN FACTORS

Cantemir Mambet 15

HOW?

*Examples of human factors to include in a PHA:

- Controls and indications:

- Accessibility

- Clarity

- Usability

- Task overload

- Work schedules

*Human factors in PHA does not address ergonomics

Cantemir Mambet 16

HOW?

- People

- Procedures

- Equipment

- Environment

- Management

EXAMPLES OF CATEGORIES OF HUMAN FACTORS

*Generally, the process industries in EU and US do not

use standards and guidelines for human factors

*Some individual companies have developed internal

guidelines

*Standards and guidelines exist in other industries

Cantemir Mambet 17

HOW?

PEOPLE

EXAMPLES OF CATEGORIES OF HUMAN FACTORS.

GUIDELINES & SAMPLE QUESTIONS

-What is the educational level of the workforce?

-What is the literacy of the workforce?

-What is the first language of the workforce?

-What is the training level of the workforce?

Cantemir Mambet 18

HOW?

PROCEDURES



-Who wrote the procedures - engineers or operators?

-What is the reading comprehension level of the

operators?

-How long are the procedures? - documents more

than about 10 pages intimidate many operators

-Can items be found easily and quickly?

-Are warnings and cautions clearly distinguished?

-How big is the type font?

Cantemir Mambet 19

HOW?

EQUIPMENT



-Is equipment labeled?

-Are switches and lights on control panels arranged

in a logical manner?

-Can key indications be seen from the locations

where the adjustments are made?

-Are DCS displays too busy or confusing?

-Do DCS displays correspond to the P&IDs?

Cantemir Mambet 20

HOW?

ENVIRONMENT



-Is the temperature and humidity comfortable for

long-term human working conditions?

-Is it too comfortable?

-Is lighting adequate everywhere it is required?

-What is the noise level?

-What is normal traffic through the workspace - are

there distractions?

Cantemir Mambet 21

HOW?

MANAGEMENT



-Have sufficient resources been made available?

-Are there enough people to perform the required

actions in the required times?

-Do direct supervisors have decision-making

authority?

-Are decisions made quickly when needed?

Cantemir Mambet 22

• Simple checklists

• Auxiliary checklists

• Incorporate explicit human factors study (in

HazOp, What-If). Usually it is HAZOP causes or

what-if questions that are annotated

• Human factors affect the human failures recorded

in the cause or what-if columns

• [BACK-UP SLIDES]

• Separate explicit human factors study

APPROACHES TO TREATMENT OF HUMAN FACTORS

IN A PHA

HOW?

Cantemir Mambet 23

• Can be used by the team leader to remind the team of the

types of human factors issues that must be considered

Entries are made in the PHA worksheet that identify human

factors problems and their impact on hazard scenarios

(more detailed checklist of human factors issues can be

used:

– As a backup for completeness

– To stimulate the team's brainstorming

– As a quality control check

• Similar to the use of checklists of human failures

• The same cautions as before apply

SIMPLE CHECKLISTS TREATMENT OF HUMAN FACTORS

ISSUES DURING A PHA

HOW?

Cantemir Mambet 24

• Operator/process and operator/equipment interface

• Clarity, simplicity, accessibility and usability of controls and

indications

• Automatic instrumentation vs. manual procedures

• Number and frequency of tasks operators must perform

• Impacts of extended or unusual work schedules, including shift

rotations

• Design of tasks

• Operator feedback

• Communications systems

• Clarity of signs and codes

• Environment

EXAMPLE OF SIMPLE CHECKLIST OF HUMAN FACTORS

ISSUES

HOW?

Cantemir Mambet 25

HOW?

• Many human factors engineering issues can be

handled on a one-time or global basis

• These issues include:

– Control room

– Personnel assignments

– Work routines

• PHA team leaders must be careful also to

consider human factors issues at a local level

– e.g. The readability of a particular instrument

GLOBAL VS. LOCAL HUMAN FACTORS ISSUES

Cantemir Mambet 26

HOW?

• Specify the immediate human factors problem

and the underlying cause, as appropriate

– E.g. Valve difficult to operate due to lack of

maintenance

– Do not need to brainstorm all possible root

causes

• Identify the dominant ones

GUIDELINES FOR RECORDING HUMAN FACTORS

Cantemir Mambet 27

DIFFERENCE

HUMAN FAILURES

(HFACS) based on model developed by J. Reason (Human Error.

New York: Cambridge University Press, 1990)

”Swiss Cheese” model for latent and active failure conditions

Influences from organisation

Unsafe supervision

Preconditions

Unsafe acts

Ill defined ProceduresLabor issuesLow morale

Task allocationFailure to correctWillful disregard

FatigueComplacencyLoss of Situational Awareness

Crew Actions

HOW?

Cantemir Mambet 29

HOW?

APPROACHES TO TREATMENT OF HUMAN FAILURES

-Simple brainstorming

-Checklists

-Structured brainstorming

-Explicit human failure study

Cantemir Mambet 30

HOW?

SIMPLE BRAINSTORMING

*Human failures can generally be identified

adequately by brainstorming in PHAs as causes of

hazard scenarios

- Along with equipment failures and external events

*The team should be questioned after each deviation

or subsystem to determine whether all significant

human failures have been identified by considering:

- All the people who are involved

- The various functions they may perform

- The different types of mistakes they may make

Cantemir Mambet 31

HOW?

CHECKLISTS

*Checklists of specific human failures can be used to

prompt the team to identify applicable failures.

*They can range from simple reminder checklists to

detailed checklists

*Use of reminder checklists is a common approach

Cantemir Mambet 32

HOW?EXAMPLE OF CHECKLIST OF SPECIFIC HUMAN FAILURES

- Operator performs an operation when none is required or desired

- Operator performs more than is required

- Operator performs less than is required (incomplete or partial

action)

- Operator performs action on the wrong equipment

- Operator performs the reverse or opposite of what is required

- Operator fails to take a reading when required

- Operator makes incorrect reading

- Operator does not believe indications (does not acknowledge

alarm, ignores reading)

- Operator inactivates an alarm system for convenience

- Operator ignores out-of-specification test/inspection results and

continues to operate with no special or additional protection

- Operator bypasses a trip, interlock, or other safety function for

convenience

Cantemir Mambet 33

HOW?

- Reminder checklists need to be kept short if they

are to be effective

- PHA teams will become frustrated if they have to

repeatedly consider detailed checklists

- Detailed checklists can be used:

- As a backup for completeness

- To stimulate brainstorming of human failures

when the PHA team needs assistance

- As a quality control check by the team leader

subsequent to a PHA session

Cantemir Mambet 34

HOW?

• Human failures can be identified by combining elements of

three simple checklists

• Process similar to combining guide words with parameters

to generate deviations in a HAZOP study except that three

items are combined

• Formula: Person + Facility Aspect + Failure Type = Specific

Human Failure

•Example: "Operator" + "Procedure" + "Action is not performed"

identifies the failure: “Operator does not follow the procedure”

[BACK-UP SLIDES]

STRUCTURED BRAINSTORMING OF HUMAN

FAILURES IN PHAs

Cantemir Mambet 35

HOW TO USE CHECKLISTS IN STRUCTURED

BRAINSTORMING

• Must review:

– List of people to ensure everyone involved has been considered

– Facility list for completeness of tasks/functions

• Lists are usually similar for different facilities, but not

necessarily identical

• Failure list assists in ensuring that all types of human

failures have been identified for the different ways people

interact with the facility

• It is important to understand that items in the three

checklists are not combined in a formal, exhaustive way

• The checklists are simply reviewed to identify any

combinations that may have been missed by the team

brainstorming

Cantemir Mambet 36

HOW?

• It is possible to perform a more detailed analysis that looks

at human failures exclusively, in more detail than is

possible in a PHA

• Such studies have been performed routinely in some

industries

• They are not yet common in the process industries

EXPLICIT HUMAN FAILURE STUDY

Cantemir Mambet 37

• Identify underlying causes

– E.g. pressure gauge is installed incorrectly

(teflon tape omitted, cross-threaded, etc.)

– Do not need to brainstorm all possible root

causes

• Identify the dominant ones

GUIDELINES FOR RECORDING HUMAN FAILURES

HOW?

Cantemir Mambet 38

CONCLUSIONS?

• Regulators wants human failures and human

factors to be considered in performing PHAs

• This is routinely done for human failures in most

PHAs

• Human factors engineering issues can also be

considered within a PHA

• It is preferable to conduct a separate study prior

to the PHA

• There is still uncertainty as to the extent to which

human factors must be treated to satisfy

Regulators

Cantemir Mambet 39

WHY?

Cantemir Mambet 40

References

•EU "Seveso III" Directive (2012/18/EU) Safety Management Systems & Safety

Reports

•Institution of Chemical Engineers, European Process Safety Center, 2000 - HAZOP

Guide to Best Practice

•Hazard and Operability Studies (HAZOP Studies) – Application Guide, IEC 61882:2001

•29 CFR 1910.119, OSHA’s Process Safety Management Standard

•40 CFR Part 68, EPA’s Risk Management Program Rule

•ISO 31000:2009,“Risk Management - Principles and Guidelines”. November 15, 2009.

•ISO Guide 73:2009, Risk Management – Vocabulary

•IEC/ISO 31010:2009, Risk Management – Risk Assessment Techniques

•Jeff Kotson, Commander, U.S. Coast Guard, „Risk Management”, Presented to the Air

Charter Safety Foundation JSSC 1998

•Cantemir Mambet, Human Factors. Their impact on risk management, Presentation

Petroleum Club Romania, June 2013

Cantemir Mambet 41

Back-up slides

Cantemir Mambet 42Cantemir Mambet 42

PRECAUTIONARY PRINCIPLE

*In the European Union, risk management practice is

guided by the precautionary principle:

“The Community has consistently endeavored to achieve a

high level of protection, among others in environment and

human, animal or plant health. In most cases, measures

making it possible to achieve this high level of protection can

be determined on a satisfactory scientific basis. However,

when there are reasonable grounds for concern that potential

hazards may affect the environment or human, animal or

plant health, and when at the same time the available data

preclude a detailed risk evaluation, the precautionary

principle has been politically accepted as a risk management

strategy in several fields” (European Commission, 2000)


SEVESO III

*EU Major Accident Prevention Policy and Safety Management

System, as Required by Council Directive 96/82/EC (Seveso II), now

2012/18/EU Seveso III

- Preparation of a Safety Report to meet the requirements of

Council Directive 2012/18/EU Seveso III (Art. 10)

- The aim of the Seveso II Directive is two-fold

- Firstly, the Directive aims at the prevention of major-

accident hazards involving dangerous substances

- Secondly, as accidents do continue to occur, the Directive

aims at the limitation of the consequences of such accidents

not only for man (safety and health aspects) but also for the

environment (environmental aspect).


SEVESO III• The scope of the Seveso III Directive applies solely to the

presence of dangerous substances in establishments

• It covers both, industrial "activities" as well as the storage of

dangerous chemicals

- Lower tier site

• Must comply with Articles 6 and 7 of the Directive

• Notification of substance, details of facilities and assessment of immediate

environment

• Draw up major accident prevention policy

- Upper tier site

• Must comply with Articles 6 - 11 of the Directive

• Notification of substance, details of facilities and assessment of immediate

environment

• Produce safety report demonstrating that:

• A major accident prevention policy (MAPP) and safety management system

(SMS) is in place

• Major accident hazards have been identified and measures have been taken to

limit consequences


SEVESO III

- Establishments must demonstrate adequate safety and reliability

(ALARP)

- Establishments are required to provide sufficient information to

Competent Authority to enable decisions to be taken with regard

to siting new developments around existing activities

- Requirements for management policies and systems are contained

in the SEVESO III Directive

- Failures of the management system were shown

to have contributed to the cause of over 85 per

cent of the accidents reported.

*Member States require the operator to produce a safety report to:

- Demonstrate that a Major-Accident Prevention Policy (MAPP) and

a Safety Management System (SMS) have been put into effect;


SEVESO III

- Demonstrate that major-accident hazards have been identified and

that the necessary measures have been taken to prevent such

accidents and to limit their consequences

- Demonstrate that adequate safety and reliability have been

incorporated into the design, construction, operation and

maintenance of any installation, storage facility, equipment and

infrastructure connected with its operation which are linked to

major-accident hazards inside the establishment.

*The safety report must include information on the:

- Environment of the establishment

- Description of the installation (incl. listing of hazardous

substances)

- Risk analysis and prevention methods

- Control and limitation of the consequences of an accident


SEVESO III

*Seven fundamental elements should be included in the Safety

Management System

- Organization and personnel

- Identification and evaluation of major hazards

- Operational control

- Management of change

- Planning for emergencies

- Monitoring performance

- Audit and review

- PHAs that identify and evaluate the

major hazards


SEVESO III

- Safety Report must be reviewed and updated every five years or

- At the request of the Competent Authority

- At the initiative of the operator (voluntary), where justified

by

- New facts

- New technical knowledge about safety

- New knowledge about hazard assessment

- In case of modification of a site (Art. 10)

- Therefore the PHA and Risk Analysis must be reviewed and

updated for the same reasons


PHA- Process Hazard Analysis (PHA) (or Process Hazard Evaluation) is a

set of organized and systematic assessments of the potential

hazards associated with an industrial process.

- A PHA provides information intended to assist managers and

employees in making decisions for improving safety and reducing

the consequences of unwanted or unplanned releases of

hazardous chemicals.

- A PHA is directed toward analyzing potential causes and

consequences of fires, explosions, releases of toxic or flammable

chemicals and major spills of hazardous chemicals, and it focuses

on equipment, instrumentation, utilities, human actions, and

external factors that might impact the process.

- *There are varieties of methodologies that can be used to conduct

a PHA, including but not limited to: Checklist, What if?, What

if?/Checklist, Hazard and Operability Study, Failure Mode and

Effects Analysis.


- PHA methods are qualitative in nature. The selection of a

methodology to use depends on a number of factors, including the

complexity of the process, the length of time a process has been in

operation and if a PHA has been conducted on the process before,

and if the process is unique, or industrially common.

- Other methods such as Layer of Protection Analysis (LOPA) [1] or

Fault Tree Analysis (FTA) may be used after a PHA if the PHA team

could not reach a risk decision for a given scenario.

- In the US, the use of PHAs is mandated by the Occupational Safety

and Health Administration (OSHA) in its Process Safety

Management regulation for the identification of risks involved in

the design, operation, and modification of processes that handle

highly hazardous chemicals.

PHA


HUMAN FACTORS WORKSHEET ENTRIES



- AUXILIARY CHECKLIST -


HUMAN FACTORS REVIEW WITHIN HAZOP

EXAMPLE OF HUMAN FACTORS IN A GLOBAL NODE


HUMAN FACTORS REVIEW WITHIN HAZOP

EXAMPLE OF HUMAN FACTORS IN A LOCAL NODE


HUMAN FACTORS REVIEW WITHIN WHAT-IF

EXAMPLE OF HUMAN FACTORS IN A GLOBAL SYSTEM


HUMAN FACTORS REVIEW WITHIN WHAT-IF

EXAMPLE OF HUMAN FACTORS IN A LOCAL SYSTEM


CHECKLISTS FOR BRAINSTORMING HUMAN FAILURES

People

- Operators

- Engineers/Designers

- Maintenance/Testing/Inspection

- Emergency Responders

- Sampling/Lab

- Supervision

- Management

- Contractors

- Material Handlers/Fork Lift Truck Drivers



Facility

- Process

- Instrumentation

- Controls

- Alarms

- Interlocks

- Shutdowns

- Safeguards

- Safety equipment

- Instructions (verbal)

- Procedures (written)

- Equipment

- Communications

- Emergency response

- Environment



Failures

- Action is not performed

- Action is performed incorrectly

- Action is performed in wrong place

- Action is performed in wrong sequence

- Action is performed at wrong time

- Non-required action is performed

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